The next item is the statement by the Cabinet Secretary for Health and Social Services on winter pressures. Vaughan Gething.

Thank you, Deputy Presiding Officer. Across Wales, our health and social care services have faced significant pressures this winter. None of the challenges we face in Wales are unique to us; the same challenges exist right across the UK. It is testament to the compassion and commitment of our staff that the vast majority of people continue to receive the care they need in a compassionate, professional and timely manner, and I would like, once again, to thank and pay tribute to our hard-working staff for the dedication they have shown in managing and coping with the pressures across our health and care system over the last few months, and I am sure everyone here will share those sentiments.

Despite rigorous preparation across our system, there have been times when our services have seen exceptional levels of activity above and beyond what could reasonably have been anticipated. GPs' and primary care services, both in and out of hours, have seen increased activity, with twice as many patients being seen and treated following the Christmas period. So, to support GPs, I have already relaxed the quality and outcomes framework element of the GP contract until the end of March. This will help GPs and their teams to maintain focus on their most vulnerable and chronically sick patients.

The ambulance service has exceeded the 65 per cent red-call target every month since the clinical response model was introduced. December 2017 was above 70 per cent for the twenty-first consecutive month, despite receiving the highest recorded number of red calls. December 2017 was also the busiest December on record in accident and emergency departments across Wales, with 136 more attendances per day compared to the same month last year. More patients were treated, admitted or discharged within four hours than in any of the previous three Decembers, and that reflects the hard work of staff, who've maintained a typical wait of just over two hours before patients were admitted or discharged. December also saw the highest number of patients aged 85 and over being admitted to hospital from an A&E. As we know, older people often have more complex needs, requiring longer periods of assessment in A&E, and, if they are admitted, they are more likely stay longer in the hospital.

Dealing with pressure in our system is a year-round challenge. We see higher levels of attendance in the summer, but the highest proportion of people, and, in particular, vulnerable people, needing care are present in the winter. However, the monthly four-hour A&E performance in 2017 was better during every month than in 2016, with the exception of a very difficult December.

As Members will know, I have visited several A&E departments and spoken to clinicians in recent weeks to see the challenges faced by front-line staff for myself. The Minister for Children and Social Care has also been out speaking to staff on the ground, and we will both be doing more of this across Wales in the coming weeks. The extraordinary levels of demand this year have been compounded by an increase in patients suffering with flu, norovirus and respiratory illness attending GP practices and A&E. This flu season has seen the highest rates of illness since 2010-11, exacerbated by the cold snap across the UK in early December. Flu rates appear to have peaked, but they still remain high and the flu season will continue for a number of weeks yet.

There are, though, areas of our system that have improved despite the recent pressures. We've seen a 7 per cent reduction in delayed transfers of care in December, confirming that the total number of delays during 2017 was the lowest since our records began 12 years ago. Waiting times have stabilised in respect of referral to treatment and diagnostics, and we expect material improvements to the end of March. Health boards do have clear profiles to achieve this in place. As you know, we provided an additional £50 million to help health boards build on the progress made over the last two years, to reduce the number of patients waiting over 36 weeks, those waiting over eight weeks for diagnostics and those waiting over 14 weeks for therapy services by the end of March.

We continue to provide nearly £43 million to support our primary care services through the primary care fund, and our £60 million integrated care fund is being used to provide care and support closer to home, to keep people out of hospital, and to tackle delayed transfers of care. For example, the Môn enhanced care model in Anglesey is delivering care at home for acutely ill elderly patients. The Stay Well at Home service in Cwm Taf is using a multi-disciplinary hospital-based team to undertake assessments and commission support services to prevent unnecessary hospital admission, and indeed to help people to get back to their own homes in the first place.

We have recently provided an additional £10 million to support front-line services to take immediate action to improve care. Cwm Taf Local Health Board have extended GP practice opening hours on weekends to support the out-of-hours service, and there are early signs that is helping patients to avoid A&E. Hywel Dda has increased therapy, social worker and consultant resource to support weekend discharges, and Cardiff and Vale health board has commissioned additional rehabilitation beds to support patients with their ongoing care needs. Our early information indicates that 69 per cent of patients transferred to the unit have reduced care needs from the point of admission to being discharged.

The social care sector and staff play an equally important role in delivering care and have faced the same considerable pressures this winter. In recognition of that, I'm pleased to confirm that I have provided an additional £10 million to local authorities to address their most immediate priorities in this area. Following discussions with the Welsh Local Government Association and the Association of Directors of Social Services in Wales to identify those priorities, this extra money will be used to provide domiciliary care packages, care and repair services to enable quicker discharge from hospital and maintain independence at home, and for short-term and step-down residential care.

Although winter preparation has delivered a greater resilience across our system, there have been times where people have experienced longer waits than are acceptable. The national evaluation of planning and delivery for last winter identified a need to focus on planning for December and immediately after the festive period. So, health boards introduced initiatives this winter that focused on collaborative working and being proactive through escalation to address those pressures quickly and improve patient flow. There is some variation across Wales, but our early indications are that this has increased resilience, means that more patients are being sent home earlier in the day, it's reduced the average length of stay for patients who would typically wait in hospital in a bed for over a week, and health boards and their partners will be expected to evaluate their actions and share learning right across Wales.

There are areas of the system where the exceptional demand has meant, without additional planned actions, pressure would have escalated to critical levels. We've provided nearly £700,000 to the Welsh ambulance service to increase the number of clinicians in their contact centres to 30. This allowed patients to be safely treated over the telephone or to be diverted to other services, resulting in a substantial reduction of unnecessary ambulance journeys to hospital. But all of us can play our part in supporting the national health service. We need to make the right choices for ourselves, but also encourage our constituents to choose the appropriate advice or service when they are sick or injured.

I'll close by saying that winter is not over yet. I've seen some people suggesting that winter is over at the end of February. We should remind ourselves that, last year—there was an exceptionally cold March last year. So, winter does not neatly end at the end of February. Pressure remains in our system at this point in time, and there will inevitably be more difficult days to come. We will continue to work closely with our staff, across health and care services, to ensure the very best outcomes possible for our people by delivering the right care at the right time and in the right place.

I'd like to thank the Cabinet Secretary for his statement today. Your opening paragraph I couldn't agree with more. I too would like to add my thanks and recognition of the hard work that not just the NHS staff do, but also all those who work within social services and within the care sector, to help us get through what is traditionally a very, very difficult time of the year. I welcome the improvements that you cite in your statement. Those positive examples are very thought-provoking. However, it is not all roses, and I think that serious questions remain over the way that services were planned for this winter. We waited until the summer for a review of last year's winter resilience, which was clearly far too late, I think, to learn lessons and develop robust plans, and the health and social care committee heard this constantly—witness after witness after witness, representing organisations, groups and individual GP practices and consultants across Wales, saying that they hadn't been involved in winter pressures. 

When you've got 46 A&E consultants who have penned a letter to the First Minister, saying that the safety risks are unacceptable, then we should be very critical about how we handle the winter. When you had, during the height of the winter demand, at Swansea's Morriston Hospital, personal assistants, IT staff and managers called upon to chase up scan results and even medication to help reduce delays, we have to question how we did this winter. We had the Royal College of Emergency Medicine saying that some patients in Wales waited more than 80 hours in emergency departments.

So, there are four questions that I'd like pose to you, and first about bed occupancy. Last year alone, there was an 8 per cent reduction in rehabilitation beds, 6 per cent in psychiatry, 6 per cent in general surgery and almost 6 per cent in geriatric medicine. You stated that health boards had been supported to open additional beds this winter, but it obviously did very little to alleviate demand. So, Cabinet Secretary, I wondered if you could tell us what went wrong with that—why Prince Philip had 103 per cent bed occupancy over those two weeks of winter, Withybush at 98, Bronglais at 100 per cent, Royal Gwent at 98, Nevill Hall at 98. They are staggeringly high, and I would like to understand how the £50 million that you gave earlier last year, the £10 million you recently gave for front-line services—and I do welcome the £10 million you've announced in this statement today for the social care sector—. But, you know, it's not getting to where we need it. Bed occupancy is a major problem.

My second area of concern was about out-of-hours care. The 4-3-4 nature of those two weeks over Christmas and new year really seems to have caught people on the hop. In Aneurin Bevan, we only had 20 doctors on shift when we actually needed 28. Cardiff and Vale—just 92 GP hours were worked despite 192 being needed. I could go on and on. We had GPs unable to cover the out-of-hours, so people of course then ended up going to the hospitals and putting all that pressure on our A&E services.

Turning to A&E, over that two-week period—I'm not going to bore you with statistics; I've got them all here—how many patients were waiting well over the 12 hours? But, when you think that the Heath hospital was able to plan for the UEFA cup final by saying to every single ward, 'You must clear two beds in order for us to be able to manage any influx we may have'—that kind of level of detailed planning didn't take place for the winter pressures. If you look at the Heath, they had almost two wards full of people waiting for a transfer of care to leave hospital, and I think that that must have added to that pressure enormously.

My final point is about influenza. GP consultation rates for influenza were well above the moving epidemic threshold. That means we were reaching—or had reached—crisis point. There was an enormous increase in flu, and I would like to understand, Cabinet Secretary, what you can do to improve the take-up of the flu jab. When we think that only 51 per cent of NHS staff had a flu vaccination, and only 53 per cent of NHS staff who were in the front line had a flu vaccination, then we can see that we actually have to do something about this.

Finally, on the NICE guidelines, the vaccine this year was the £5 trivalent vaccine, and that did not include the influenza B, which has caused over 50 per cent of hospital admissions. That other vaccine would have cost £8. So, I would like your commentary on whether or not you feel that a lesson going forward is that we should try and get a more comprehensive vaccine available to stop it. It is flu, particularly in the young and the elderly, that causes so much pressure on our A&E. There's an awful lot more to say about winter pressures, and I do recognise the green shoots of success that you highlighted. How to make them consistent and how to apply them universally across the NHS is the challenge you face, but you have absolutely got to be forensic in understanding why and where we were not successful this year. 

Thank you for the questions and the comments, and in particular your opening and the recognition of the contribution of our staff in what is still the most testing time of the year.

I'll start with your final points on the flu season. On the vaccine, we always work with partners across the UK in trying to order and agree on the most appropriate form of vaccine for the most likely strain. With the different strains that exist in the flu season each year, there is always an element of trying to understand what that should be, but we make those choices sensibly and carefully as healthcare systems—there isn’t a particular difference, as it were, between different nations. And it’s still the case that the flu vaccine is the most effective protection people have against flu before the flu season, and, actually, part of my concern is that, every year, somebody says that the flu vaccine isn’t at all effective.

So, we do need to encourage greater take-up, which goes back to your point about encouraging greater take-up amongst health and care staff on the front line, as well as at-risk members of the public. Because I have had a previous kidney condition, I am in an at-risk group myself, so I have the flu vaccine every year. So, I don’t just have someone stick a needle in my arm in a community pharmacy for the sake of a photo op; I actually do need the jab myself as well. And it’s something we can do in a small role, demonstrating some leadership. But, this year, actually, we started with a campaign fronted by the then Minister for public health. We’ve actually seen an increase in take-up across health and care staff, so I look forward to seeing what the final figures are, and then to see what further improvement we need to make, because there is absolutely no pretence that where we are in terms of staff take-up in particular is adequate or we’d like to say that the situation is resolved, because it certainly is not. I’ve seen for myself at first hand the closures and reduction in capacity that the flu outbreak has meant. When I was in Wrexham Maelor A&E recently, they were closing off an area because they had three confirmed flu cases in there. So, it does affect real capacity within the service, and there’s a knock-on impact from that through the front door and the back as well.

I guess that takes me to your point about transfers of care, then, as well. Because part of what we need to do is to think about how we actually get people out of the hospital part of the system when they no longer need to be there. That’s why the anticipatory part of those models of care matters. The Ynys Môn model really matters, because a lot of that is about keeping people in their own homes, as well as about getting them out. That’s why it’s a good thing that, in the last year, we’ve had a good record on delayed transfers of care, but there's much more still to do. But the £10 million that I have announced today to go into the social care system should help us to get people out of the hospital system and into a more appropriate point for their care to take place, because we recognise that, at any point, we’ve had 300 to 400 medically fit people across the system. And, actually, if you could release those people to go back into their own homes, where they’ll need support, then actually we'd have a much greater amount of capacity for people who do need a hospital bed. That would reduce waits, be a more appropriate way to deliver care, and deliver dignity and appropriateness, and we’re likely to see better outcomes as well. So, we need to be looking at investing in different parts of our system at points in time, and it’s also why the teams that I talk about—if you like, the community rehab and community resource teams—are a really important part of that as well.

On out of hours, there is a mixed picture. It’s been fragile in different parts of the country at different points of time, and, again, there’s no point in pretending that that is a fixed issue. I think 111 still gives us the best model moving forward to help fix some of that out-of-hours challenge across the country, and there’s something there about that helping to manage and underpin the out-of-hours service rather than wholly replacing it. And if you look at what’s happened in Swansea, Neath Port Talbot and, indeed, Carmarthenshire, we’ve seen a real improvement there as well. So, there’ll be more to come, and I’ll be utterly transparent with the Chamber again as we have that evaluation and the step forward in 111 and its further roll-out.

Just on your point about the evaluation of winter and, in particular, I think, about bed capacity, well, we’ve introduced about 400 extra beds across our system—so, if you like, the size of a normal-sized district general hospital. And yet, still we recognise real challenges in capacity across the whole system. So, in the evaluation of winter that we’ll undertake with the Royal College of Emergency Medicine and others, we’ll need to look again at what’s happened this winter, how successful that has and hasn’t been at various points in time and, I think, at where we need extra capacity across our system, whether that’s extra capacity in the hospital part of the system with the staff that we need to have to do that, or whether, actually, if we had extra beds, we'd simply fill them up with more people and not improve flow across our system as well. That’s where we need to think about smart investment choices, either to keep people in their own homes or to get them out of a hospital, and I think that’s the first point to go to. Actually, that was the first point of action in the letter from the consultants at the Royal College of Emergency Medicine, about investing more in social care. To help us to do that, to lead some of that clinical consensus, we have appointed Jo Mower as a national clinical director for unscheduled care. Jo is an emergency department consultant based in Cardiff, and part of her role will be some of that leadership and looking at national systems leadership and local practice across the country. I think she'll be well received by her peers in emergency departments across the country as one part of our response to this whole-system challenge.

I'll keep my comments fairly brief. I haven't been here all that long, but already there's a feeling of groundhog when it comes to discussing winter pressures. There's no doubt that there have been some extraordinary episodes of increased pressure over this winter, and I would like to pay tribute to the astoundingly dedicated members of staff right across our health and care services in Wales who have been trying to deal with the situation that they have been faced with over the past months. You're quite right that they continue to face it up towards the end of winter. But fundamental questions: do we think there'll be a winter next year? I think there will be. What then, assuming there'll be one, are the fundamental shifts that we can look for signs of from this Government that will put the NHS in Wales in a stronger position in order to deal with those pressures when they inevitably come? Because they do.

I was at Ysbyty Gwynedd a matter of 10 days ago, getting the latest insight into the situation there: near 100 per cent bed occupancy, if not 100 per cent. I think the day I was there they were expecting 50 patients in. There were 54 patients in beds in Ysbyty Gwynedd that didn't need to be there. You can see where the problem is. If not every day, every few days I'm hearing tales of patients having their elective surgery cancelled. This is what's happening. This is causing untold distress for those patients and their families, and it is causing delays to treatment that will have who knows what effect on their recovery from the illnesses that they face—[Interruption.] I'm more than happy to take an intervention—

No.

—but being a statement, I'm sure you can make your point in questions to the Cabinet Secretary later.

So again: when are we going to see that fundamental shift towards a sustainable health and care system in Wales that can deal with the winter of 2018-19, and the winter of 2019-20 and beyond? That's all Welsh patients are asking for.

Thank you for the questions and comments. Again, I'm grateful, as I'm sure staff are, for the tribute paid again by the Plaid Cymru spokesperson to the manner in which staff have responded to the at times exceptional pressure and demand that we recognise within the system.

Turning to your questions, this winter, as with last winter and the winter before, we're seeing health and social care some together to plan for winter. So, this isn't an exercise of central Government control. We help to hold the ring with people coming together, and they look at and plan together in their local circumstances. That's actually been helpful, with social care and health recognising that they really do need each other. That may sound obvious, saying that out loud, but for different parts of public services to take time away and actually plan together isn't always a straightforward and easy thing to do. It's consistent with our policy direction and indeed with what the parliamentary review has said, and actually there's something about continuing to do more and to do better with that joint planning right across our system.

It is a system challenge, because your point about medically fit patients, and the fact that they're still often in a hospital bed when they know there are more coming in—well, that is about health and social care together. Some of those people will need to be in a different part of the national health service for the next part of their care and treatment. Some of them could be supported in their own home, whether that's a residential home or a nursing home, or, if you like, a traditional private home, but they'll need social care and support to get there. That's why, in my statement, I pointed out some of the things that are already happening, and things that we could see to, and we'd want to have not just policy levers, but practical incentives to do that as well. The integrated care fund is one of those, but we think we'll need to do more.

That isn't just the Government's view, of course, but that is also the view of the parliamentary review. When they called for a seamless care system, they're looking more and more at examples of what is successful and encouraging us as politicians in the Government and beyond to look at how we actually help healthcare and social care to build on a more consistent basis. Because we always know there will be a winter every time, every year. We know that it may vary in terms of the scale and the pressure, but there will always be extra pressure, because apart from anything else we can expect next year there to be even more people over the age of 85 coming in to our hospitals. We know that is a reality we will face. It's about how fast our system can move to catch up with the challenge of the demand that we see and how fast we can actually move outside the hospital, crucially, to manage some of that demand.

I just want to respond directly to your point about elective procedures. This is something about the contrast between the system here and across our border. In England, they announced a ban on elective procedures to help manage through winter. So, a total ban through England. We didn't do that in Wales. We have unfortunately seen some people have their care interrupted, but I still think that, whilst people are frustrated, if they have their elective procedure cancelled or postponed, most people understand that it's being done because there is an emergency within the system where somebody needs that care on a more urgent basis. 

Nevertheless, 22,000 people have had elective procedures through December. There is significant activity taking place. What we need to be able to do across our whole system, in balancing elective and emergency admissions, is to think about how quickly we can get those people who have had elective procedures postponed back in to have that procedure, which we understand that they will need.

It's part of the challenge in running a dynamic system and an understanding that, even though we have reduced the level of elective admissions to cope with winter, at times of extreme pressure, the system will need to make choices, and that often will be about postponing elective procedures because the emergency is at the door. I know what I would want if that were me or a member of my family. I know how I would feel if that was also my elective procedure being postponed. So, there is a need to be sensible and mature about our system and think about how we improve that again, if at all possible, for the year ahead. That's certainly our expectation in the Government.

Can I thank the Cabinet Secretary for his statement today, and can I join others in thanking the dedication and commitment of all our NHS and care staff across Wales? I'm sure I speak for every Member in this Chamber when I give those thanks, because they have given the service above and beyond what they normally would do anyway, and always do that, and they don't just do it in the winter pressures, they do it throughout the whole year. Can I remind Members in the Chamber that my wife is a member of the NHS and therefore is in the front-line services, so I put that on record? Can I also welcome the investment in social care to improve the care packages that are available to get people out of the hospital? Because we all agree that that is one of the problems—it's people not getting out through the system fast enough to ensure that beds become available as people come in to the front end. It's critical that we address that.

However, we still have those problems at the front end. In your statement, you identified 65 per cent of the red calls target being met. I appreciate that, but the reality is that's one in three not receiving the red call target in time. Therefore, we need to address that because they then have a knock-on effect on the amber calls, which receive delays. I've had many constituents who have been in touch with me recently about 14 to 15-hour waits for ambulances and being told, 'Don't move the patient if they've had a fall', and a vulnerable elderly patient who has had a fall is sitting on the floor waiting for an ambulance. That amber call becomes a red call the longer they wait. Therefore, we do need to address that.

I appreciate the challenges of investing in the ambulance service, but we need to make sure that those ambulances get there on time and get the patients to the hospital on time, so that the ambers don't become red and the patient doesn't stay in the hospital longer than necessary. In one case, I had a patient who had to actually wait in hospital for two or three days whilst they stabilised before they could actually have an operation on the hip they'd broken. So, it is important we address those issues. So, I'm asking the question as to how you're going to ensure that process happens quickly so that we don't get more ambers becoming red and patients waiting for those hours.

Can I also highlight—you mentioned earlier in an answer that the 111 system in AMBU is being piloted. It is actually working, it was referred to us last week in a briefing I had, and it does offer a great deal of choices to patients and to relatives who phone the 111 service and get different answers and maybe therefore no longer need an ambulance but get a better service. But in the situations when they do need an ambulance, can I highlight this point? I phoned the ambulance headquarters last week, wanting to get hold of somebody to get an ambulance out to a patient. I got a number and was told—this was after hours—'Phone the contact centre.' Three times I phoned the headquarters and checked that number, because five times the answer came back, 'This number is not recognised.' That's not acceptable. We need to address that, so that when someone needs to get hold of them, they can get hold of them. So, can we please address that?

Rhun ap Iorwerth talked about the electives, and I appreciate what your comments were on those electives, and I do understand that emergencies come in and those emergencies take priority. I understand that. But many patients are being cancelled. Can you give me perhaps—? I'm happy to do that in writing, in a letter, but how many were postponed? How many were cancelled over the period we're talking about, not just December, but from the start of the winter—let's say November—to perhaps the end of February now, and see hwo many patients—? Because that has a knock-on effect as well, and it's important that we address the knock-on effect of those electives being postponed and delayed, because, again, we've seen situations in the summer that therefore mean that we get pressures in the summer. 

And can you also tell me of the investment into the primary care system—? I welcome that, totally welcome it, particularly as we understand the difficulties in GPs being recruited in to cover out-of-hours sessions, and that's one of the problems we have, so the wider community service is important. But can you tell me how much funding was actually put into district nurses, because district nurses are facing very serious challenges, and have you specifically ring-fenced any of that funding for district nurses? If not, will you be looking at how funding for district nurses is being applied across the health boards to ensure that they're able to undertake their duties in the community, which takes the pressure off the GPs, which then takes the pressure off A&E, so there's an actual consequence on—? 

And I'll leave it at that, because I can see the Deputy Presiding Officer telling me to sit down. 

Thank you. I was just thinking of the word I was going to use to say politely, 'Could you wind up?', but thank you very much. Cabinet Secretary.

Thank you. And thank you, David Rees, for the series of questions, and you're right to highlight not just the professional capability and commitment of our staff, but also the fact that the service runs on the goodwill of those staff as well. 

I want to try and deal with your final point about telephony issues and elective postponements and district nursing budgets as well. I think it's best, given that you've asked me for information on elective postponements from November to February, that I write to you at the end of the February period. I have a number of abilities, but being extra sensory perception-savvy is not one of them. I can't predict the future in that way, so I'll write to you at some point in March when the figures are available. 

It is worth noting, though, because I've answered a written question from Angela Burns recently on this, that of the postponements in December for elective procedures, over half of them were postponed by the patient, and so there's a challenge there about working across the whole system to try and make the whole system work better. That's not about blaming people who have postponed; it's actually about how we better organise our whole system. 

On your other point about care packages to help people out of hospital, that's exactly why we've tried to help direct the £10 million with the advice and support of the Welsh Local Government Association and directors of social services, again looking at it as a whole system. I think it comes back to your point about long ambulance waits, because the easy and the straightforward thing to say is that, of course, I don't want, and no person in this room wants people to wait overly long for an ambulance, whether it's a red, amber or even a green call. The challenge then is what we do about understanding the issues behind some of those long ambulance waits, and that is only possible to see if we look at the whole system. For those ambulances that are held up outside an emergency department while they're waiting to be released, while there's risk in the community that has still got to be managed, there are differences and variations in practice across the country about how quickly that happens, but not only that—it's about recognising that there's a challenge at the front door, but also then to flow through the hospital so that the rest of the hospital system sees the front door as their challenge as well, and not just an issue for the emergency department itself. As with the package of care, there is an issue about reducing the backlog to get people out of hospital when they're medically fit, so to give them the support that they will need to do so. That must be a challenge that health and social care recognise that they own jointly for that individual citizen.

And it's then also looking at the use of local healthcare as well, and how we help people to make the right choices and how we support them to do so, and how we also deal with some of the use of the ambulance service itself. There's been really groundbreaking work undertaken by Cardiff and Vale about those people who regularly misuse the service, but some of that is about understanding what health and care need they do have even it isn't an emergency ambulance. That in itself is releasing lots of extra capacity for our ambulance crews. 

So, it's about all of those points and recognising again what we could and should make in each part of them to try and deal with those longer waits, and not simply say, 'This is the problem with the Welsh ambulance service trust itself', but how as a whole system do we see the opportunities to improve.  

Thank you for your statement, Cabinet Secretary, and I would also like to place on record my thanks to all the dedicated staff for the way that they've handled pressures this winter.

Spring is just around the corner, but our NHS remains in the depths of a winter crisis, with many operations being cancelled, and therefore we cannot move on. I should rephrase that, because the term 'winter pressures' gives the impression that pressures upon the NHS in winter are unique; unfortunately, they are not. Our NHS is facing spikes in demand year round, often made worse by the backlog created as a result of dealing with winter pressures. The only thing different about the winter months is an increase in respiratory illnesses and perhaps a spike in trips and falls due to snow and ice.

So far, winter 2017-18 has been much milder than 2010-11 and flu rates have been lower, so why, after so much planning and investment, is the NHS struggling more this year? At this stage in 2010-11, consultations for influenza-like illnesses were nearly double what they are today and 86 per cent of patients arriving at A&E were discharged within the four-hour target. Cabinet Secretary, do you believe that the very fact that we had 2,000 more beds and occupancy rates below 85 per cent enabled the NHS to cope better back then?

And also, Cabinet Secretary, although consultation rates for influenza-like illnesses are much lower than in 2010-11, they are still much higher than the seasonal average. So, do you agree that the decision to offer the cheaper trivalent vaccine, which does not protect against the most prevalent B strain, is the biggest contributing factor to the spike in flu cases and will you now opt for the slightly more expensive quadravalent vaccine, which protects against B-Yamagata, or Japanese flu, the most prevalent B strain this winter?

It is clear that we can’t afford to continue approaching seasonal pressures in the same fashion. And while we look forward to your vision for the future of our NHS, this winter has made it abundantly clear: we need radical changes now.

So, Cabinet Secretary our NHS needs better signposting for patients, and while the Choose Well campaign is a step in the right direction, it is still not having the complete desired effect. So, what plans do you have to expand the 111 service to cover the whole of Wales and to act as a gateway to services, signposting patients to the most appropriate resource, whether that’s a pharmacy, a primary care team or A&E?

I was also concerned to hear via a meeting that those training to be GPs—only 30 per cent to 40 per cent have stated that they are willing to work out of hours. This is a great concern to me and to other people.

Finally, Cabinet Secretary, how do you plan to bolster NHS resources so that we aren’t having this exact conversation in three months' time, in six months and again at this time next year? Thank you very much.

Thank you for the comments and questions. I wish that spring really were around the corner, but, as I said earlier, there can be no guarantee that winter neatly comes to an end on St David's Day.

I would say that winter really is different. I just don't think it's correct to say that the pressure is year-round and that it's no different in winter and that we just have a bit more respiratory illness. In going around emergency departments right across the country, there's been a very consistent theme that is borne out in the facts and figures on the number of 85-year-olds in our hospital emergency departments and hospital beds, and that is that, in winter, we do see a larger number of very sick, very frail people and often much older people. And that is what creates the pressure, because the numbers go down but actually the challenge and the demand for the hospital capacity for really sick people who need to be in a hospital bed go up. And more of those people will spend more time in our A&E units and in our hospital beds, and that is what creates much of the pressure, and indeed pressure in local healthcare as well. That's why I announced the relaxation of the quality and outcomes framework too. Again, much of our conversation otherwise ends up being about ambulances and hospitals.

On bed capacity and flu, I think I dealt with those points in answer to the first set of questions from Angela Burns. We will of course listen to the evidence from Public Health Wales, their surveillance evidence on the circulation of flu, the type and what we should do for the next year.

On 111, again in response to Angela Burns's question, I indicated that we would have something on a national roll-out for 111 over the coming years. And on pharmacy, I'm really pleased that you mentioned a number of things we could do differently with Choose Well—Choose Pharmacy being one part of that. The last time I updated Members, 60 per cent of pharmacies in the country had the Choose Pharmacy system; it's now 66 per cent of community pharmacies that have access to Choose Pharmacy. That's a real success story, and we are piloting a roll-out of further access to the GP record in community pharmacies—I'll know more about that at the end of March—to make a different choice. And in that, we are ahead of both Scotland and England in actually having that greater access for our community pharmacies. So, we're investing in different parts of our system to give people opportunities to access that advice and support in every community, on a much easier basis.

Thank you. Finally, Jenny Rathbone.

Thank you very much, Deputy Presiding Officer. I wanted to pay particular tribute to the chair of Cardiff and Vale University Local Health Board, Maria Battle, who I ran into on the corridors of the Heath hospital in the week before Christmas. She was clearly going around, every single day of the week, ensuring that all her staff were being properly looked after, and dealing with particular issues as they arose. That is real leadership. So, I join everybody else in saying how thankful we are that we have such dedicated nurses, doctors and ancillary staff who, together, provide the glue to provide the sort of care that very vulnerable people need.

The average age of people in the Heath hospital is 85. So, it's obviously very, very complicated when somebody gets admitted for a medical issue to then get them back home again, reliving their independent lives, after a medical incident. So, I'm very pleased to read about the extra rehabilitation beds that Cardiff and the Vale have laid on, because that ensures that people are actively being enabled to get back home and get on with the rest of their lives appropriately.

I'm very interested in what you mentioned about Cwm Taf having extended GP hours on the weekend, and emerging evidence that this was actually reducing the demand for A&E, because that indicates to me that people are inappropriately turning up at A&E simply because they are not able to wait to see their GP in the community.

I suppose the other two things I just wanted to mention are the importance of having 24-hour catering facilities for people who we expect to work 24 hours—we want to ensure that people still have hot food when they're working through the night; and also that we are properly looking at the weather guide in order to ensure that we know when there is going to be a spike in demand. I wondered if you could just say whether that is happening in all our health boards.

Thank you for that. Actually, on your last point, it is something that the service definitely does look at, because after a cold snap, you can anticipate that from about five to seven days onwards, you'll see an influx of patients as a result of that cold snap. That's part of the extra exacerbation of pressure in January, because of the December cold snap. But, equally, some of the other cold periods that we've had through the rest of this winter have seen additional flows into our emergency departments. It's an undeniable part of where we are, and having enough flex in our ability to plan for staff capacity and bed capacity is part of our very real challenge in managing and running the service.

I take on board your point about hot food, and I'll come back to you on that particular point, because I do recognise the point you're making about staff. That also goes into your very welcome opening comments about Maria Battle. I think all chairs in health boards take very seriously the privilege they feel about getting to do this job within the national health service and recognising that, as well as challenging the leadership of the health board to have a strategy and success for the future, actually, they want to be there to support staff. And you'll see lots of chairs and vice-chairs who take the opportunity to go around and have that interaction with staff. It is almost always welcomed by people who otherwise may not know who the chair of the health board is, apart from maybe a picture in an entrance that they may well have stopped looking at some time ago. So, it's a really good example of the commitment right across the healthcare system.

I just want to deal with your final point about admissions and recognising age. We come back to this challenge of what that means for our system, because if you admit someone because they have one particular thing that has gone wrong with them that causes an admission, you often find that they have other healthcare challenges as well. The danger is that if you say, 'I will now treat all of those things whilst you're in a hospital', you potentially end up keeping that person there for longer. There's something, then, about what that does to that person, because if they've been managing those other challenges relatively successfully, and they're happy to deal with that risk in their own home, there's something about how paternalistic our system can potentially be, where we're saying to people, 'You are not allowed to manage this risk in your own home', as opposed to, 'How do we help and support you to manage this risk in your own home, which you've done successfully up to this point in time?' That's not to say that people who have undiagnosed conditions that they could and should be helped with shouldn't be, but it's still about a conversation with that person, and that goes into the heart of having a more equal relationship between the healthcare provider and the citizen. What is the challenge? What is the issue? And, how do we talk about it and agree on a way forward? That, in itself, would help to release some of our time and capacity, because hospital is a great place to be if you're really ill and you need a service, and need some emergency care, in particular. But, actually, particularly once you're older, if you're there and you're delayed and you can't get out, it starts to cause a different challenge for you with a lack of mobility and a potential for other risks as well from being in the hospital system. So, it's in everyone's interest to have that greater flow out of our system if they no longer need to be there, and how we help and support people to have as much care as possible in their own homes.

Thank you very much, Cabinet Secretary.

The next items on our agenda this afternoon are the Regulation and Inspection of Social Care (Wales) Act 2016 (Consequential Amendments) Regulations 2018 and the Social Care Wales (Specification of Social Care Workers) (Registration) (Amendment) Regulations 2018. In accordance with Standing Order 12.24, I propose that the following two motions under items 5 and 6 are grouped for debate. Does any Member object? No. Good.